Bulletin of Emergency And Trauma

Abstract The HELLP syndrome is an important variant of pre-eclampsia which is known by triad of hemolysis (H), elevated liver enzymes (EL) and low platelet count (LP). Intraparenchymal liver hematoma is a rare and important complication of HELLP syndrome which is a life threatening condition. The incidence of intraparenchymal hematoma of the liver has been reported to vary from 1 in each 40,000 to 250,000 deliveries worldwide. Herein we report a case of intraparenchymal liver hematoma following HELLP syndrome. An 18 year- old woman with moderate to severe preeclampsia after delivery, presented with Right upper quadrant (RUQ) pain and tachycardia and significant drop in hemoglobin level. Ultrasonography revealed intraparenchymal liver hematoma. This finding was also confirmed by computerized tomography (CT)-scan. Conservative treatment was applied and the patient improved without need of any surgical intervention. Spontaneous hepatic hematoma should always be considered as a life threatening and important complication of HELLP syndrome during pregnancy and it can be managed conservatively in a hemodynamically stable patient.

Abstract Objective: This study evaluated the occupational burnout (OB) and spiritual well-being (SWB) of emergency
nurses as well as the associations between these variables.
Method: This cross-sectional study was conducted in six hospitals and emergency medical centers affiliated with
Ardebil University of Medical Sciences (Ardebil, Iran), in 2020. Data were collected via socio-demographic,
Spiritual Well-Being Scale (SWBS), and Maslach Burnout Inventory (MBI) questionnaires.
Results: This study included 239 emergency department nurses. The mean age of the participants was 34.4±6.4
years. The mean of existential well-being and religious well-being was 40.3±8.7 and 41.0±9.2, respectively. The
results indicated that moderate (P=0.007) and severe (P<0.001) personal accomplishment was a positive and
significant predictor of the SWB in emergency department nurses.
Conclusion: Proper planning and provision of suitable educational programs in the dimension of the SWB
of nurses prevent the creation and continuation of OB and increase the self-efficacy and job satisfaction of
emergency medical staff, resulting in better patient care.

Abstract Objective: To examine all aspects affecting the functioning of the system and the most important factors in its assessment through a systematic review during 1990 to 2017.
Methods: This systematic review of the current literature study was conducted during July 2017, and all articles, books, guidelines, manuals and dissertations pertaining to the Incident Command System were analyzed. A total of articles and relevant documents were identified and finally these articles, which we found, were analyzed based on the specified indicators.
Results: In this research 992 articles and relevant documents were identified and eventually, 48 articles were included and analyzed. The results were categorized into 6 main groups including 65 subgroups and 221 variables: features  of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system (10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the  effectiveness of system  include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables).
Conclusion: According to the results, Evaluating the effectiveness of a hospital accident command system (HICS) in a valid method can improve the efficiency of this system. In this appraisal, hospital managers and health decision-makers should consider principles, characteristics, strengths and weakness of it.

Abstract Objective: This study aims to characterize the demographic, clinical, and radiological features of gunshot
wound (GSW) patients as well as identify predictors of prolonged hospitalization.
Methods: In this retrospective study, a consecutive sampling method was used, including all patients with
GSWs in any anatomical region. Data collection included demographic and clinical information, radiological
findings, treatment specifics, and outcome variables, such as hospitalization length of stay (LOS) as the primary
outcome. To identify predictive factors associated with prolonged LOS, logistic regression analysis was used.
Results: We studied 212 GSW cases, including 95.8% were men and 4.2% were women. The mean age of the
studied group was 30.17±7.80 years. GSWs occurred in extremities (80.2%), abdomen (9.0%), thorax (4.7%),
and head or neck (5.2%). Two patients (0.9%) had both abdominal and thoracic GSWs. The most prevalent
radiological study was an X-ray (83.0%). Patients with head and neck GSWs had the longest emergency
department stay, while patients with abdominal GSW patients had the shortest (p=0.068). The highest rates
of blood product transfusion were observed in abdominal GSWs (63.2%), emergency surgery (63.2%), and
ICU admission (42.1%). Head and neck GSWs had the longest hospitalization LOS (7.5 days). Longer LOS
was significantly associated with abnormalities in radiological findings, receiving blood products, and ICU
admission (p≤0.001). Significant predictors of prolonged LOS were major abnormalities in radiological findings
[odds ratio (OR)=5.3; 95% confidence interval (CI):2.8-10.2], head and neck GSWs (OR=6.1; 95% CI:1.2-31.9),
and blood product transfusion (OR=4.1; 95% CI: 1.0-16.3).
Conclusion: This study provides insights into factors influencing prolonged hospitalization in GSW patients,
highlighting the importance of radiological findings, head and neck injuries, and blood product transfusion.

Abstract Approaching posterior fossa pathologies is fairly challenging. Poor exposure, Cerebrospinal Fluid (CSF) leak following surgery, post-operative suboccipital and neck pain, and wound healing are common challenges following traditional suboccipital midline incision. Herein, we present a new incision for approaching posterior fossa pathologies. The incision is shaped like a question mark and makes a musculofascial flap supplied by occipital artery on top of providing a wide area for craniotomy. In our technique, the dura is also incised in a question mark shaped manner. Three patients with masses in posterior fossa were operated with the new incision. Following surgeries, there were no adverse events including CSF leak, wound complications, severe suboccipital pain and neck instability in any of the patients. This new incision not only facilitates approaching to pathologies in posterior fossa with providing wider exposure, but also enables us for watertight Dural closure which decreases CSF leak. Also, as the muscular incision provides a sufficient area for craniotomy, muscular retraction can be minimized to avoid post-operative pain. Moreover, as opposed to the midline avascular incision, the flap is well supplied by occipital artery which facilitates the healing procedure.

Abstract Objective: This study aimed to compare the outcomes of fixing scapholunate with pins and screws in parallel,
convergent, and divergent orientations.
Methods: In this computer simulation study, the CT scan images of a healthy subject were
used to construct a 3D model of the wrist joint using MIMICS software. The imposed force to scaphoid and
3D model lunate bones, as well as the scapholunate angle and distance, were compared in different surgical
techniques using parallel, divergent, and convergent pins and screws.
Results: In the absence of external force, the imposed stress applied to the scaphoid and lunate bones in cases
of parallel pins and screws were 7.5MPa, 5.08MPa (pins), 1.134MPa, and 1.151MPa (screws), and 10.90MPa,
10.90MPa (pins), 9.7MPa, and 34.1MPa (screws) for 50N flexion force. The imposed stress in this approach is
significantly lower compared to other interventions. Better outcomes were seen regarding scapholunate angle
and scapholunate distance in using parallel pins or screws as well.
Conclusion: In conclusion, implementing parallel pins and screws for scapholunate fixation had better results
in terms of achieving carpal stability in scapholunate dissociation. However, fixation with pins and screws
showed a statistically significant difference. Furthermore, a wide range of motion exercises with no additional
forces can be used in the rehabilitation of patients undergoing this surgery.

Abstract Objective: To derive findings from different studies done on drug related hospital admissions and comprehensively express the incidence and preventability of drug related hospital admissions; identify the common types of drug related problems that caused hospital admission, and identify factors associated with drug related hospital admission.
Methods: Literatures that assessed hospitalization due to drug related problems were searched online using Pub Med and Google Scholar databases. The relevant reference lists of retrieved articles were also searched manually on Google. Prospective and retrospective studies conducted anywhere in the world on drug related hospitalization, published from January 2012 to January 2017 as an original article and written in English language were included.
Result: The prevalence of drug related hospital admission varies from 1.3% to 41.3% with the average rate of 15.4%. Among hospitalized patients 2.7% were died due to drug-related problems (DRPs). Drugs that were frequently reported as causing drug related admission were antithrombotic drugs, antihypertensive drugs, analgesics, anti-diabetics, antipsychotics, and anti-neoplastic drugs.  Poly pharmacy, old age and female sex were mentioned as determinants for drug related hospitalization by a number of studies. About one third of drug related hospital admissions were definitely preventable and more than 40% were also potentially preventable.
Conclusion: Drug related problems contribute for more than 15% of hospital admissions. Higher risk of admission due to DRPs was observed in patients who were on poly pharmacy and those who were old. As most of drug related hospital admissions were preventable an emphasis should be given for preventive strategies to avoid complications and costs associated with admission.

Abstract This paper offers a historical exploration of how death was diagnosed in Persian medicine, highlighting the evolution of diagnostic criteria and the contributions of key scholars. In the post-medieval era, defining death and establishing diagnostic criteria underwent significant development, albeit with ongoing debates. Notably, medieval Persian scholars, such as Qutb al-Din al-Shirazi, played a crucial role in this discourse. Qutb al-Din al-Shirazi, a prominent Persian polymath, synthesized earlier knowledge to provide a comprehensive set of diagnostic criteria for death in traditional Persian medicine. These criteria encompassed physical examinations like assessing nail shininess, feeling pulsatile vessels in specific areas, observing pupillary reactions to light, and even monitoring the movement of a thread near the mouth and nose. His mention of the pupillary light reflex is one of the earliest known references to this phenomenon in medical history. Medieval Persian practices also involved placing a water container on the chest of the individual to detect the absence of chest wall motion associated with respiration as a sign of death. Furthermore, scholars like Ibn-e Sina (Avicenna) stressed the importance of monitoring pulse and respiration as vital signs, especially when administering potentially lethal drugs. In cases of uncertain diagnosis, such as stroke, medieval Persians postponed burials for up to three days. These historical insights provide a fascinating glimpse into the evolving understanding of death in Persian medicine and the intricate methods used for its diagnosis.